Provider Demographics
NPI:1598701906
Name:JOHNSON, RONALD BRUCE (PHD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:BRUCE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 LODI ST
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:WI
Mailing Address - Zip Code:53555-1418
Mailing Address - Country:US
Mailing Address - Phone:608-592-2080
Mailing Address - Fax:608-592-7120
Practice Address - Street 1:336 LODI ST
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:WI
Practice Address - Zip Code:53555-1418
Practice Address - Country:US
Practice Address - Phone:608-592-2080
Practice Address - Fax:608-592-7120
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2177-057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39127800Medicaid
WI44371Medicare PIN
WIR04443Medicare UPIN